Operative treatment of 2-part surgical neck fractures of the proximal humerus (AO 11-A3) in the elderly: Cement augmented locking plate Philos™ vs. proximal humerus nail MultiLoc®

Tobias Helfen, Georg Siebenbürger, Marcel Mayer, Wolfgang Böcker, Ben Ockert, Florian Haasters, Tobias Helfen, Georg Siebenbürger, Marcel Mayer, Wolfgang Böcker, Ben Ockert, Florian Haasters

Abstract

Background: Proximal humeral fractures are with an incidence of 4-5 % the third most common fractures in the elderly. In 20 % of humeral fractures there is an indication for surgical treatment according to the modified Neer-Criteria. A secondary varus dislocation of the head fragment and cutting-out are the most common complications of angle stable locking plates in AO11-A3 fractures of the elderly. One possibility to increase the stability of the screw-bone-interface is the cement augmentation of the screw tips. A second is the use of a multiplanar angle stablentramedullary nail that might provide better biomechanical properties after fixation of 2-part-fractures. A comparison of these two treatment options augmented locking plate versus multiplanar angle stable locking nail in 2-part surgical neck fractures of the proximal humerus has not been carried out up to now.

Methods/design: Forty patients (female/male, ≥60 years or female postmenopausal) with a 2-part-fracture of the proximal humerus (AO type 11-A3) will be randomized to either to augmented plate fixation group (PhilosAugment) or to multiplanar intramedullary nail group (MultiLoc). Outcome parameters are Disabilities of the Shoulder, Arm and Hand-Score (DASH) Constant Score (CS), American Shoulder and Elbow Score (ASES), Oxford Shoulder Score (OSS), Range of motion (ROM) and Short Form 36 (SF-36) after 3 weeks, 6 weeks, 3 months, 6 months, 12 and 24 months.

Discussion: Because of the lack of clinical studies that compare cement augmented locking plates with multiplanar humeral nail systems after 2-part surgical neck fractures of the proximal humerus, the decision of surgical method currently depends only on surgeons preference. Because only a randomized clinical trial (RCT) can sufficiently answer the question if one treatment option provides advantages compared to the other method we are planning to perform a RCT.

Trial registration: Clinical Trial ( NCT02609906 ), November 18, 2015, registered retrospectively.

Keywords: Humeral head; Nail; Osteoporosis; Osteosynthesis; Plate.

Figures

Fig. 1
Fig. 1
Randomization and follow-up workflow

References

    1. Palvanen M, Kannus P, Niemi S, Parkkari J. Update in the epidemiology of proximal humeral fractures. Clin Orthop Relat Res. 2006;442:87–92. doi: 10.1097/01.blo.0000194672.79634.78.
    1. Baron JA, Karagas M, Barrett J, Kniffin W, Malenka D, Mayor M, et al. Basic epidemiology of fractures of the upper and lower limb among Americans over 65 years of age. Epidemiology. 1996;7(6):612–8. doi: 10.1097/00001648-199611000-00008.
    1. Helmy N, Hintermann B. New trends in the treatment of proximal humerus fractures. Clin Orthop Relat Res. 2006;442:100–8. doi: 10.1097/01.blo.0000194674.56764.c0.
    1. Kannus P, Palvanen M, Niemi S, Sievanen H, Parkkari J. Rate of proximal humeral fractures in older Finnish women between 1970 and 2007. Bone. 2009;44(4):656–9. doi: 10.1016/j.bone.2008.12.007.
    1. Nho SJ, Brophy RH, Barker JU, Cornell CN, MacGillivray JD. Management of proximal humeral fractures based on current literature. J Bone Joint Surg Am. 2007;89(Suppl 3):44–58. doi: 10.2106/JBJS.G.00648.
    1. Neer CS., 2nd Displaced proximal humeral fractures. I. Classification and evaluation. J Bone Joint Surg Am. 1970;52(6):1077–89.
    1. Neer CS., 2nd Displaced proximal humeral fractures. II. Treatment of three-part and four-part displacement. J Bone Joint Surg Am. 1970;52(6):1090–103.
    1. Handoll HH, Ollivere BJ, Rollins KE. Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev. 2012;12:CD000434.
    1. Ockert B, Braunstein V, Kirchhoff C, Korner M, Kirchhoff S, Kehr K, et al. Monoaxial versus polyaxial screw insertion in angular stable plate fixation of proximal humeral fractures: radiographic analysis of a prospective randomized study. J Trauma. 2010;69(6):1545–51. doi: 10.1097/TA.0b013e3181c9b8a7.
    1. Ockert B, Siebenburger G, Kettler M, Braunstein V, Mutschler W. Long-term functional outcomes (median 10 years) after locked plating for displaced fractures of the proximal humerus. J Shoulder Elbow Surg. 2014;23(8):1223–31. doi: 10.1016/j.jse.2013.11.009.
    1. Sproul RC, Iyengar JJ, Devcic Z, Feeley BT. A systematic review of locking plate fixation of proximal humerus fractures. Injury. 2011;42(4):408–13. doi: 10.1016/j.injury.2010.11.058.
    1. Haasters F, Prall WC, Himmler M, Polzer H, Schieker M, Mutschler W. Prevalence and management of osteoporosis in trauma surgery. Implementation of national guidelines during inpatient fracture treatment. Unfallchirurg. 2015;118(2):138–45. doi: 10.1007/s00113-013-2500-4.
    1. Unger S, Erhart S, Kralinger F, Blauth M, Schmoelz W. The effect of in situ augmentation on implant anchorage in proximal humeral head fractures. Injury. 2012;43(10):1759–63. doi: 10.1016/j.injury.2012.07.003.
    1. Roderer G, Scola A, Schmolz W, Gebhard F, Windolf M, Hofmann-Fliri L. Biomechanical in vitro assessment of screw augmentation in locked plating of proximal humerus fractures. Injury. 2013;44(10):1327–32. doi: 10.1016/j.injury.2013.05.008.
    1. Kathrein S, Kralinger F, Blauth M, Schmoelz W. Biomechanical comparison of an angular stable plate with augmented and non-augmented screws in a newly developed shoulder test bench. Clin Biomech. 2013;28(3):273–7. doi: 10.1016/j.clinbiomech.2012.12.013.
    1. Krappinger D, Bizzotto N, Riedmann S, Kammerlander C, Hengg C, Kralinger FS. Predicting failure after surgical fixation of proximal humerus fractures. Injury. 2011;42(11):1283–8. doi: 10.1016/j.injury.2011.01.017.
    1. Egol KA, Sugi MT, Ong CC, Montero N, Davidovitch R, Zuckerman JD. Fracture site augmentation with calcium phosphate cement reduces screw penetration after open reduction-internal fixation of proximal humeral fractures. J Shoulder Elbow Surg. 2012;21(6):741–8. doi: 10.1016/j.jse.2011.09.017.
    1. Somasundaram K, Huber CP, Babu V, Zadeh H. Proximal humeral fractures: the role of calcium sulphate augmentation and extended deltoid splitting approach in internal fixation using locking plates. Injury. 2013;44(4):481–7. doi: 10.1016/j.injury.2012.10.030.
    1. Mihara K, Tsutsui H, Suzuki K, Makiuchi D, Nishinaka N, Yamaguchi K. New intramedullary nail for the surgical neck fracture of the proximal humerus in elderly patients. J Orthop Sci. 2008;13(1):56–61. doi: 10.1007/s00776-007-1193-3.
    1. Foruria AM, Carrascal MT, Revilla C, Munuera L, Sanchez-Sotelo J. Proximal humerus fracture rotational stability after fixation using a locking plate or a fixed-angle locked nail: the role of implant stiffness. Clin Biomech. 2010;25(4):307–11. doi: 10.1016/j.clinbiomech.2010.01.009.
    1. Edwards SL, Wilson NA, Zhang LQ, Flores S, Merk BR. Two-part surgical neck fractures of the proximal part of the humerus. A biomechanical evaluation of two fixation techniques. J Bone Joint Surg Am. 2006;88(10):2258–64. doi: 10.2106/JBJS.E.00757.
    1. Lekic N, Montero NM, Takemoto RC, Davidovitch RI, Egol KA. Treatment of two-part proximal humerus fractures: intramedullary nail compared to locked plating. HSS J. 2012;8(2):86–91. doi: 10.1007/s11420-012-9274-z.
    1. Naidu SH, Bixler B, Capo JT, Moulton MJ, Radin A. Percutaneous pinning of proximal humerus fractures: a biomechanical study. Orthopedics. 1997;20(11):1073–6.
    1. Horn J, Gueorguiev B, Brianza S, Steen H, Schwieger K. Biomechanical evaluation of two-part surgical neck fractures of the humerus fixed by an angular stable locked intramedullary nail. J Orthop Trauma. 2011;25(7):406–13. doi: 10.1097/BOT.0b013e3181ffdf9a.
    1. Zhu Y, Lu Y, Shen J, Zhang J, Jiang C. Locking intramedullary nails and locking plates in the treatment of two-part proximal humeral surgical neck fractures: a prospective randomized trial with a minimum of three years of follow-up. J Bone Joint Surg Am. 2011;93(2):159–68. doi: 10.2106/JBJS.J.00155.
    1. Schulz KF, Altman DG, Moher D, Group C CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials. BMJ. 2010;340:c332. doi: 10.1136/bmj.c332.
    1. Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG) Am J Ind Med. 1996;29(6):602–8. doi: 10.1002/(SICI)1097-0274(199606)29:6<602::AID-AJIM4>;2-L.
    1. Roderer G, Gebhard F, Krischak G, Wilke HJ, Claes L. Biomechanical in vitro assessment of fixed angle plating using a new concept of locking for the treatment of osteoporotic proximal humerus fractures. Int Orthop. 2011;35(4):535–41. doi: 10.1007/s00264-010-1021-9.

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